Synthesis

In the 2002 edition of the British Medical Journal, its editor Richard Smith attempted to define the concept of "non-disease". His conclusions are summarized as follows: the concept of "disease" is a slippery one—so is "medicine". Health is also impossible to define. To have a condition labelled as a disease may bring considerable benefit—both material and emotional. But the diagnosis of a disease may also create problems in the denial of insurance, mortgage, and employment. A diagnosis may also lead to patients regarding themselves as forever flawed and unable to "rise above" their problem.

There is increasing evidence of a neurobiological, genetic, psychological, and social nature which indicates that bipolar disorder is at the very least a disorder. If disease is defined as the presence of clear and reproducible pathology, such evidence is not yet available in the case of bipolar disorder. However, modern biotechnology is providing methods which can provide information in vivo concerning the nature of the functional abnormalities in conditions such as schizophrenia and the affective disorders.

The issues for the future include the questions of whether schizophrenia and bipolar affective disorder are on a continuum of psychosis and whether a broad or narrow definition of bipolar is the most useful from both a clinical and a research viewpoint.

As new research techniques develop, it will be possible to answer part or all of these questions. The central diagnostic importance placed on alterations in mood distracts from the more subtle but nevertheless meaningful symptoms, such as changes in psychomotor function and cognition. Advances in neuroimaging paradigms which incorporate neuropsycho-logical tests have revealed some of the neurofunctional similarities and differences between diagnostic subgroups. Importantly, more information than ever is available concerning the correlation between structural and functional brain changes and symptoms expressed by patients suffering from bipolar disorder and schizophrenia. One of the great challenges ahead is the separation of state from trait phenomena and to increase our understanding of common fundamentals in mental disorder. In other words, what are the first principles which underlie mental functions and the abnormalities therein? Cognition, emotion, and behaviour offer templates with which to examine the symptoms in disorders such as the bipolar. Clinical observation, while useful, is no longer sufficient for exploring the baseline abnormalities in these disabling disorders. Debates surrounding definitions, broad versus narrow, inclusive versus exclusive, may be answered by greater understanding of the common pathways that underlie the symptoms expressed.

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